Rule 20:06:13:0B Form for Reporting Medicare Supplement Policies.
DEPARTMENT OF REVENUE AND REGULATION
DEPARTMENT
OF LABOR AND REGULATION
DIVISION
OF INSURANCE
FORM
FOR REPORTING
MEDICARE
SUPPLEMENT POLICIES
Chapter
20:06:13
APPENDIX
B
SEE:
§ 20:06:13:53
Source: 18 SDR 225, effective July 17, 1992;
39 SDR 10, effective August 1, 2012.
APPENDIX B
FORM FOR REPORTING
MEDICARE SUPPLEMENT POLICIES
Company Name: ______________________________
Address: ______________________________
______________________________
Phone Number: ______________________________
Due
March 1, annually
The purpose of this
form is to report the following information on each resident of this state who
has in force more than one Medicare supplement policy or certificate. The
information is to be grouped by individual policyholder.
Policy
and Date of
Certificate
# Issuance
___________________________________
Signature
___________________________________
Name
and Title (please type)
___________________________________
Date
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